Medical Management of Recurrent Left Ventricular Assist Device Thrombosis in a Patient With Biventricular Assist Devices.

Ventricular assist device (VAD) pump thrombosis is a known complication and while the preferred standard treatment is surgical pump exchange this procedure is not without risk and for some patients the risks are prohibitive. This is a case of a 68-year-old female with bilateral HeartWare ventricular assist devices (HVAD) implanted as destination therapy who presented with signs of recurrent pump thrombosis. Surgical pump exchange was deemed to confer prohibitive risk due to her underlying medical co-morbidities and therefore not an option for treatment. After careful consideration of possible options for treatment, she received systemic thrombolysis (Alteplase 5 mg IV bolus followed by 3 mg/hour infusion for 10 hours through a central line) which was successful. This case highlights, not only the rarity of bilateral VADs as destination therapy, but also demonstrates the safety and efficacy of using systemic thrombolytics in patients with bilateral HVADs for treatment of pump thrombosis.

Patient-Centered and Specialty-Specific Case Work-Up: An Effective Method for Teaching Appropriateness of Imaging to Medical Students.

RATIONALE AND OBJECTIVES: Our institution has developed a mini-course program within the diagnostic radiology elective curriculum that promotes active learning, using patient cases specifically tailored to students' future specialties. The purpose of this study is to evaluate the effectiveness of this mini-course on medical student knowledge of imaging appropriateness and attitude toward radiologist consultation. MATERIALS AND METHODS: During each month-long radiology elective course, students were divided into teams of up to four students based on their specialty interest and assigned recent patient cases with imaging findings relevant to their specialties. The students researched their customized patient cases, integrated pertinent clinical and imaging findings, and presented their findings in a final preceptor-led session. A five-point Likert-type item preprogram and postprogram survey assessing knowledge of imaging appropriateness and attitude toward radiologist consultation was sent to the enrolled medical students. RESULTS: Out of 36 medical students, 33 (92%) completed the preprogram survey and 31 (86%) completed the postprogram survey. Students reported improved confidence in knowledge of imaging appropriateness, such as indications for intravenous contrast (p < 0.0005) and oral contrast (p < 0.0005). Furthermore, students reported an improved understanding of how to utilize radiologists (p < 0.005) and how to provide pertinent clinical historical information when requesting a radiology exam (p < 0.0005). Students reported that researching the patient's historical and clinical information in conjunction with the radiology images made them more invested in the case. CONCLUSION: Assigning customized patient cases to medical students on diagnostic radiology elective, tailored to their future specialties, is an effective and active way to teach imaging appropriateness and to improve attitudes toward radiologist consultation.

Effective Treatment of Symptomatic Lower Esophageal (Schatzki) Rings With Acid Suppression Therapy: Confirmed on Barium Esophagography.

OBJECTIVE: Symptomatic lower esophageal (Schatzki) rings are one of the most common causes of dysphagia and esophageal food impaction. Although these rings are often diagnosed fluoroscopically, patients are typically referred for dilation procedures performed by a gastroenterologist. Because these procedures are invasive and carry risks, including esophageal perforation, an alternative treatment option is needed. Although recent research has shown the effectiveness of acid suppression medications used in addition to dilation procedures, our objective was to evaluate the effectiveness of treatment with acid suppression medication alone. MATERIALS AND METHODS: We retrospectively evaluated a cohort of nine patients who underwent barium esophagography at our institution to determine the ability to pass a 13-mm barium tablet and to identify a change in the lumen diameter of the lower esophageal rings after treatment with an oral proton pump inhibitor medication. RESULTS: The median ring diameter was 10 mm (range, 8-15 mm) before treatment and 15 mm (range, 13-25 mm) after treatment, a statistically significant difference (p = 0.008). The median tablet passage score was 2 before treatment (with tablet passage paused briefly) and 1 after treatment (with the tablet passing through the esophagus easily without stopping), which was also a statistically significant difference (p = 0.02). CONCLUSION: Significant improvements in both the ring lumen diameter and the ability to pass a tablet through the esophagus indicate that acid suppression medication is an effective alternative to the use of dilation procedures for the treatment of Schatzki rings.

A new approach to learning how to teach: medical students as instructional designers.

As students at the David Geffen School of Medicine at UCLA, the student authors were given the opportunity to develop their own creative projects which would be used to teach future medical students. They chose their own topics, planned and researched their projects, and then implemented the projects in interactive digital Adobe Flash files. In the first project they created interactive case-based radiology teaching files. In the second project they integrated photographic images into the existing illustrative anatomy files. Students in subsequent years have learned from these files on computers both at home and in the school's anatomy lab. The experience of creating the files served as an opportunity for hands-on learning for the student authors, both of the material and of the practice of teaching. In this paper they describe why they undertook these projects, what exactly they did, and the impact their creation had on them. The projects demonstrate that student-driven educational materials are both possible and beneficial. Furthermore, their experience has allowed them to conclude that faculty at other medical schools should consider providing students with opportunities to develop their own creative projects that contribute to the curriculum.